Provider Demographics
NPI:1689075053
Name:WEINERT, CARLY (LSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:WEINERT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 SIMS ST STE 204
Mailing Address - Street 2:PATH
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5148
Mailing Address - Country:US
Mailing Address - Phone:701-225-3310
Mailing Address - Fax:701-225-2208
Practice Address - Street 1:135 SIMS ST STE 204
Practice Address - Street 2:PATH
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5148
Practice Address - Country:US
Practice Address - Phone:701-225-3310
Practice Address - Fax:701-225-2208
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5046104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker